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HomeMy WebLinkAboutOmaha Steaks - 12/31/2019Commonwealth of Massachusetts Town of Mansfield Town of Mansfield 6 Park Row Mansfield, MA 02048 Board of Health Permit to Operate a Food Service Establishment Type: RETAIL FOOD In accordance with Regulations promulgated under authority of Chapter 94, Section 305A and Chapter 111, Section 5 of the General Laws, a Permit is hereby granted to:. OS SALESCO, INC. Whose place of business is: OMAHA STEAKS 280 SCHOOL STREET, #D150 PERSON(S) IN CHARGE DAN OPPENHEIMER, STORE MANAGER Permit Expires: December 31, 2019 Food Fee: $125.00 License Number: RF-9 BOARD OF HEALTH 'AlichaeCHeatey, Chairman FOR BOARD OF HEALTH USE ONLY Permit FOOD ESTABLISHMENT PERMIT APPLICATI (Application must be submitted at least 30 days before the planned CT 2 5 date) Establishment Name: OMAHA STEAKS Establishment Address: 280 SCHOOL STREET, SUITE #D150 MANSFIELD, MA 02048 Establishment Mailing Address(if different): 11030 O STREET OMAHA, NE 68137 Establishment Telephone No.: (508) 261-8783 .a\.r ailing li.. -Ck L x �tTcv 1 Applicant Name & Title �t ['4. Applicant Address: j Applicant Telephone No.: (401) 935-3009 24 Hour Emergency No.: (401) 935-3009 Applicant E-mail: MARIEA@OMAHASTEAKS.COM Owner Name & Title (If different from applicant): Owner Address: Owner Telephone No.: (402) 597-8221 Owner E-mail: Establishment Owned By: If a corporation or partnership, give name, title, and home address of officers or O An Association partner. ❑® A Corporation Name Title Address O An Individual�1 El A Partnership ��f t �-� r,t •.. �'E j',r s l ,c. � a � El Other legal Entity Person Directly Responsible For Daily Operations (owner, person in charge, supervisor, manager etc.) Name & Title Address: 1 F'L% ��C I' LJt eer�IVi<<, —�1.:• b 'E \. `.C: l<l {;{�. rL't S'� Telephone No: (508) 261-8783 ® 24 Hour Emergency No: (401) 935-3009 FAX: E-mail: Alt E-Mail: MARIEA@OMAHASTEAKS.COM IM District Or Regional Supervisor (if applicable) Name & Title: BRIAN KALBERER 13 Address: 11030 O STREET OMAHA, NE 68137 Telephone No: 24 Hour Emergency No: (609) 220-7964 FAX: E-mail: BRIANK@OMAHASTEAKS.COM r 't Food Establishment Information WATER SOURCE: TOWN SEWAGE DISPOSAL: TOWN DEP Public Water Supply No: (If applicable) No. of Food Employees: 3 DAYS/HOURS: MON-SAT 10AM - 8PM SUN 10AM - 6PM Name of Person In Charge Certified in Food Protection Management If more than 3 individuals are certified, complete list is on file. Person Trained in Anti -Choking Procedures (if 25 Seats or more):El r� __._...... Location: ❑® Permanent Location — __......_._ Establishment Type ❑ Caterer $35.00 ❑Moblie Moblie Start Date: r®j Retail (ri? ` Sq. Ft) ❑ Milk & Cream $10.00 Moblie End Date: � ❑Food Service up to 100 INCLUDING ❑Mobile Food Concession Mobile Comments: FOOD TRUCKS $175.00 NO PHF PREPARED ON SITE $100.00 Length of Permit: ❑ Manufacture Frozen Dessertslice Cream [] Food Service up to 101 -200 $250.00 $25.00/freezer © Annual — ---- ❑_ Food Service up to 201 + $300.00 ❑ Pushcart $50.00 R of Pushcarts: Seasonal ❑ Residential $100.00 Seasonal Dates Supermarkets $400 Retail Food $125.00 ❑ Temporary ❑ Retail Snack Food $50.00 Temporary Start Date: Temporary End Dale: Temporary Time: Rain Date:--- .._.._.... — _.___....._. Food Operations Definitions:PHF - Potentially hazardous food dime/temperature controls required) Non-PHFs -non-potentially hazardous hood(no time/temperature controls required) ,(Check all that apply): RTE- ready -to -eat foods (Ex. sandwiches, salads, muffins which need no further processing) �®] Sale of Commercially Pre Packaged Non-PHFs ❑ PHFCooked To Order ❑ Hot PHF Cooked and Cooled or Hot Held — ❑® Sale of Commercially Pre Packaged PHFs ---- ❑ Preparation of PHFs For Hot And for More Than a Single Meal Service ❑ PHF and RTE Foods Prepared For Highly 1.. __ Deliveryof Packa ed g PHFs Cold Holding For Single Meal Service ----- - J ---- — ❑ Sale of Raw Animal Foods Intended Susceptible Population Facility .._ ❑Vacuum Packaging /Cook Chill ❑ Reheating of Commercially to be Prepared by Consumer Processed Foods for Service Within 4 Hours ❑ Use of Process Requiring A Variance and/or HACCP Plan (including bare hand❑ — --- -- Customer Self -Service 111_�31cpPo,r contact alternative time as a public health Ice Manufactured and Packaged for of Non-PHFs Retail Sale control)paration ❑ Juice Manufactured and Packaged for ❑ Offers Raw Or Undercooked Food Of Other Food Operations Retail Sale Animal Origin E] Prepares Food/Single Meals for Offers RTE PHF in Bulk Quantities Catered Events or Institutional Food Service Retail Sale of Salvage, Out -Of -Date J or Reconditioned Food To be completed by the Board of Health Totai Permit Fee: — Payment is due with application ❑ waived I, the undersigned, attest to the accuracy of the information provided in this application and affirm that the food - establishment operation will comply with 105 CMR 590.000 and all other applicable law. I have been instructed by the board of health on how to obtain copies of 105 CMR 590.000 and the federal Food Code. Signature of Applicant 4 Pursuant to MGL Ch.62C, sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid stale taxes required under law Signature of Individual or Corporate Name:< - Social Security Number or Federal ID: 47-0805669 TAX CERTIFICATION FORM I certify Linder the penalties of perjury that I, to my best knowledge and belief, have filed all state tax returns and paid all state taxes required under law. Signature of Individual or Corporate Name By: Corporate Officer (Mandatory, if Applicable) "Social Security No. (Voluntary) or Federal Identification Nuinber *This license will not be issued unless this certification clause is signed by the applicant. ** Your social security number will be furnished to the Massachusetts Department of Revenue to determine whether you have met tax filing or tax payment obligations. Licensees who fail to correct their non -filing or delinquency will be subject to license suspension or revocation. This request is made under the authority of Massachusetts General Law Chapter 62C, section 49A. C:\Users\sleite\Desldop\Scott's Documents\Food Establishtoents- Temp\TAX CERTIFICATION FORNI.doe The Commonwealth of Massachusetts Department' oflndustrial Accidents Office of Investigations 600 Washington Street �c Boston, MA 02111 www.niass.govIdia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: Address: r,:?t tJ<_- Ci /State/Zi t't� t t ' z Phone #: Are you an employer? Check the appropriate box: Business Type (required): 1. [1 1 am a employer with i'�k employees (full and/ 5. E] Retail or part-time).* iv, Nk 6. ❑ Restaurant/Bar/Eating Establishment 2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8• ❑Nan -profit 3. ❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, § 1(4), and we have 10.❑ Manufacturing no employees. [No workers' comp, insurance required]** l l.❑ Health Care 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.❑ Other *Any applicant that checks box 41 most also fill out the section below showing their workers' compensation policy infdrmation. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box # I . I am an employer that is providing workers' compensation insurance for nn+ employees. Below is the policy information. Insurance Company Name: W. t'6ee Insurer's Address: City/State/Zip: Policy # or Self -ins. Lic. # <-'8 �A ­' t' t f'= Expiration Date: ` t t � i` Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGE c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of tip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties ofpe/yury that the information provided above is true and correct. Signature: l l t �_ e.h,_... , _k ct,E �`, I 1��5 � Date' tc i t, [ t Ci"� Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other Contact Person: Phone #: www.mass.gov/dia WORKERS CONDENSATION AND ENPL-YE,R9 LIABILITY INSURANCE POLICY ' Ifs ;1*]11M `iCld 11117_CC14 Issued by Liberty Mutual Fire Insurance Company (a stock company) 16586 Policy Number WA2-64D-444507-078 Issuing Office Renewal Of WA2-64D-444507-077 Issue Date Account Number 4-444507 Sub Account 1. Insured and Mailing Address Omaha Steaks International, Inc. 11030 O Street OMAHA NE 68137 Liberty Mutual. INSURANCE 175 Berkeley Street Boston, MA 02116 Lewiston, ME 06/29/2018 0000 FEIN 44-0652560 NJ TIN 470460284000 Risk ID 917128308 MI Risk ID 0701300A Status Corporation Other workplaces not shown above: See Item 4. Premium - Extension of Information Page 2. Policy Period: The policy period is from 07/01/2018 to 07101/2019 12:01 A.M, standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: AZ CA CO CT FL GA IL IN KS KY MD MA MI MN MS MO NE NV NJ NY NC OK PA RI TN TX VA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All States except those listed in Item 3.A and the States of: ND OH WA WY D. This policy includes these endorsements and schedules: See Item 3. Coverage D - Extension of Information Page 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Code Premium Basis Total Rate per $100 Estimated Annual Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page minimum t-remium $1,0uu Premium will be billed Annual Producer 0002 007662 ARTHUR J GALLAGHER RISK MANAGEMENT SERVICES INC 10050 REGENCY CIR STE 300 OMAHA NE 681143721 Total Estimated Annual Premium $ 204,V4J Deposit Premium $ 284,043 DepositTax/Surcharge/Assessment $ 5,291 Countersigned by Authorized Rep. (FL) WC 00 00 01 A O 1987 National Council on Compensation Insurance, Inc. WC 00 00 01 B (CA) Ed. 07/01/2011 All Riqhts Reserved Page 1 of 1